Supraclavicular Subclavian Line

Aka: Supraclavicular Subclavian Line, Supraclavicular Catheterization of Subclavian Vein

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II. Indications

  1. See Central IV Access
  2. Alternative central Intravenous Access
    1. Internal Jugular Vein is not accessible
    2. Access during CPR

III. Contraindications

  1. See Central IV Access

IV. Adverse Effects

  1. See Central IV Access
  2. Precautions
    1. Subclavian Line malposition into the internal Jugular Vein (may advance to CNS)
    2. Subclavian vein is a noncompressible site (Hemorrhage risk)

V. Preparation

  1. Anatomy
    1. Subclavian vein runs in parallel and well anterior to the subclavian artery
    2. Subclavian Vein courses between the clavicle and anterior first rib (and anterior scalene Muscle)
    3. Subclavian artery, is in contrast, posterior to the first rib and scalene Muscle
    4. Pleura is posterior to subclavian artery (and first rib, anterior scalene Muscle)
  2. Patient positioning
    1. Patient supine and flat on the gurney
      1. If patient hunched forward, vertically oriented towel roll between Scapulae may be needed
      2. Avoid excessive retraction of Shoulders
    2. Trendelenburg position (10-15 degrees head down) to engorge subclavian vein
    3. Head in neutral position (without neck rotation)
      1. Slight neck rotation (15 degrees) toward needle entry side may prevent malposition into IJ vein
    4. Ipsilateral arm rests at patient's side
      1. Arm may be adjucted slightly in patients with large deltoid Muscles

VI. Technique: Landmark-Based Entry

  1. Right subclavian is preferred for supraclavicular subclavian access
    1. Lower pleural dome
    2. More direct route to superior vena cava (SVC)
    3. No Thoracic Duct on the right side
  2. Prepare and drape the supraclavicular fossa
  3. Needle entry site superior to clavicla
    1. Lateral by 1 cm to the clavicular head of the sternocleidomastoid Muscle (SCM)
    2. Deep to the clavicle by 1cm
    3. Entry is approximated by the junction of the clavicle's middle third and the medial third
    4. A finger placed in the crux between the clavicle and the SCM head will direct toward the contralateral nipple
  4. Anesthetize the entry site
    1. Lidocaine 1%
    2. Using a 3 cm needle for injection can also assist with localizing the subclavian vein
      1. Typical needle entry depth is 2-3 cm
  5. Needle direction
    1. Direct the needle just below (caudal to) the contralateral nipple
    2. Needle should divide in 2 the angle formed between the clavicle and the head of the SCM
      1. Needle at 45 degrees to the sagittal and Transverse Planes
      2. Needle at 10-15 degrees below the Coronal Plane (horizontal plane with the patient supine)
    3. Orient the needle bevel medially
  6. Remainder of technique is similar to other Central Lines
    1. See Central Line
    2. Use seldinger technique

VII. Efficacy

  1. Supraclavicular approach is safer and faster than Infraclavicular Subclavian Line approach
    1. Supraclavicular approach may also be Ultrasound guided
    2. Jaiswal (2024) Indian J Crit Care Med 28(4):375-80 +PMID: 38585307 [PubMed]

VIII. References

  1. McNeil, Rezaie, Adams (2014) Central Venous Catheterization, 6th ed, Roberts and Hedges Clinical Procedures, Elsevier, p. 413-4
  2. Patrick (2009) West J Emerg Med 10(2):110-4 +PMID: 19561831 [PubMed]

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